Essential Insights On Addressing Common Wound Dilemmas
Dr. Suzuki notes that technically, one should not be prescribing antibiotics for wounds that appear uninfected. However, he notes an incidence in which that was not true. He recalls a young, healthy male in his 20s who presented with a leg wound that was chronic and non-progressing for a few months. Dr. Suzuki tried different dressings on him for several weeks and then says he prescribed cephalexin “in desperation.
“In two weeks, the wound cleared up beautifully,” he remembers. “I am not advocating giving out antibiotics randomly but I guess you have to consider the option once in a while based on the risk versus benefit.”
When would you consider switching the wound care goals from curative to palliative?
Dr. Rogers primarily defines palliative care in wound healing as the prevention of infection or prevention of wound deterioration. He emphasizes that the patient’s goals, situation and prognosis are paramount. For the patient with an ischemic ulcer without viable vascular interventional possibilities, he says palliative care may also be an option.
“I think palliative wound care may be perceived by some people as ‘giving up,’ but I do believe it is an important concept in this day and age,” says Dr. Suzuki. He cites statistics from a hospice that one-third of hospice patients die with wounds rather than from wounds. He agrees, saying that some of his wound patients do die before complete wound closure occurs.
Dr. Suzuki advocates keeping an open communication with the patients and their families. He emphasizes reviewing their expectations, treatment goals (curative versus palliative) and treatment options (aggressive/surgical versus conservative) from time to time.
“Since major leg amputation is very traumatic to our patients, I often recommend palliative wound care instead for the end-of-life patients, unless they have intractable pain or sepsis,” adds Dr. Suzuki.
If Dr. Pupp’s patients do not respond to curative wound care and they are in the end stages of a terminal disease, he will provide palliative care so as not to impair the quality of the end of life. Dr. Pupp cites the importance of keeping the patient comfortable and preventing further tissue breakdown, which is usually a result of pressure.
In the face of a recalcitrant wound, from whom would you obtain a second opinion?
Citing the importance of a team approach, Dr. Pupp seeks the second opinion of vascular/endovascular specialists if patients need increased blood flow and tissue perfusion for healing. Vascular specialists (vascular surgeons, interventional radiologists and interventional cardiologists) who can help DPMs manage arterial and venous problems are “indispensable,” according to Dr. Suzuki. Dr. Rogers also regularly consults vascular surgeons.
For patients with diabetes, Dr. Pupp will always obtain cardiology clearance/ consults. If patients do not respond to antibiotic treatment or have limb-threatening infections, he consults infectious disease specialists. He refers patients with poorly controlled diabetes to an endocrinologist.
Dr. Suzuki works closely with plastic surgeons and can consult them for input. He notes the importance of other physicians (infectious disease, nephrology, rheumatology, cardiology, etc.) in managing the wound patients, who are often older and have more comorbidities than the average population. He also notes another “second opinion” of asking patients what they think and what has worked for them.
“I think consults from multiple practitioners of varying specialties are helpful in achieving a successful outcome,” says Dr. Rogers.